Definition and Overview
Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder for which the Bárány Society published official diagnostic criteria in 2017. Non-rotational dizziness, a feeling of shaking, and instability persist almost every day for more than 3 months and are worsened by upright posture, walking, active/passive movements, and complex visual stimulation.
PPPD accounts for approximately 15-20% of patients who visit the hospital with chronic dizziness, and often occurs secondary to vestibular neuritis, BPPV, migraine, and panic disorder.
Causes and Mechanisms
Central sensory integration processing abnormalities
A healthy brain maintains balance by integrating information from the vestibular, visual, and somatosensory systems (proprioception). In patients with PPPD, after an acute vestibular disorder or anxiety attack, the brain pathologically increases dependence on vision for balance control and develops a pattern of excessive processing of vestibular and proprioceptive signals.
Autonomic dysfunction
Many patients with PPPD are accompanied by sympathetic overactivation, decreased HRV, and abnormal autonomic responses when standing. This is associated with chronic anxiety and tension and forms a vicious cycle of dizziness.
Predisposing factors
- Peripheral vestibular diseases: BPPV, vestibular neuritis, Meniere's disease
- Central Dizziness: Dizziness associated with migraines.
- Psychological factors: Panic disorder, anxiety disorder
- Other: Head trauma, post-concussion syndrome
Diagnostic criteria (Bárány Society 2017)
All of the following five criteria must be met:
1. Non-rotational dizziness, feeling unsteady, or non-rotational dizziness that lasts for more than 3 months and occurs almost every day 2. Persists or worsens in certain positions (standing, walking) 3. Triggered or worsened by active/passive movement or complex visual stimulation 4. Acute vestibular disorder, imbalance disorder, other neurological or medical disorder, or onset following an antecedent event causing psychological distress 5. Symptoms cause significant distress or functional impairment
treatment
vestibular rehabilitation therapy
The core of PPPD treatment is vestibular rehabilitation. Through habituation training, we gradually expose ourselves to visual and motion stimuli that cause dizziness and reduce hypervigilance responses. It includes training to reduce dependence on vision and actively utilize vestibular and proprioceptive senses.
medication
Selective serotonin reuptake inhibitors (SSRIs) and SNRIs are used as pharmacological treatments for PPPD. According to studies, symptom improvement was reported in approximately 50-70% of patients with chronic subjective dizziness after sertraline treatment.
Cognitive Behavioral Therapy (CBT)
CBT, which corrects dizziness-related anxiety, avoidance behavior, and maladaptive cognition, shows a significant effect in improving symptoms. Correct the misconception that dizziness is ‘dangerous’ and encourage a gradual return to activity.